Hypothyroidism - Signs and Symptoms Classic Teaching

1
Hypothyroidism - Signs and SymptomsClassic
Teaching
Symptoms Symptoms
Symptoms

• Weakness 99 Thick tongue 82 Dyspnea
  55
• Dry skin 97 Facial edema 79 Peripheral edema 55
• Coarse skin 97 Coarse hair 76 Hoarseness 52
• Lethargy 91 Skin pallor 67 Anorexia
  45
• Slow speech 91 Memory loss 66 Nervousness 35
• Eyelid edema 90 Constipation 61 Menorrhagia 32
• Feeling cold 89 Weight gain 59 Palpitations 31
• Less sweating 89 Hair loss 57 Deafness 30
• Cold skin 83 Lip pallor 57 Precordial pain 25
• Galactorrhea ?
• modified from Means, 1948

2
Hypothyroid Face
Notice the apathetic facies, bilateral ptosis,
and absent eyebrows
3
Faces of Clinical Hypothyroidism
4
Frequency of Cutaneous Findings in Hypothyroidism

• Cutaneous Manifestations Frequency ()
• Cold intolerance 50-95
• Thickening dryness of hair skin 80-90
• Edema of hands, face, and/or eyelids 70-85
• Malar flush 55
• Pitting-dependent edema 30
• Alopecia (loss or thinning of hair) 30-40
• Eyebrows 25
• Scalp 20
• Pallor 25-60
• Yellow tint to skin 25-50
• Decrease or loss of sweating 10-70

modified from Freedberg and Vogel in Werners
and Ingbars The Thyroid 6th ed.
5
Delayed Deep Tendon Reflex in Hypothyroidism

• Achilles tendon reflex time most commonly
  sought but may also be effectively tested on
  brachioradialis or biceps
• Achilles tendon reflex timing is best elicited
  with patient kneeling
• Intensity of hammer percussion should be the
  lightest possible stroke that evokes reflex

Hypothyroid
TIME
Normal
6
Graves' Disease

• Goiter
• Hyperthyroidism
• Exophthalmos
• Localized myxedema
• Thyroid acropachy
• Thyroid stimulating immunoglobulins

7
Clinical Characteristics of Goiter in Graves
Disease

• Diffuse increase in thyroid gland size
• Soft to slightly firm
• Non-nodular
• Bruit and/or thrill
• Mobile
• Non-tender
• Without prominent adenopathy

8
Clinical Characteristics of Exophthalmos

• Proptosis
• Corneal Damage
• Periorbital edema
• Chemosis
• Conjunctival injection
• Extraocular muscle impairment
• Optic neuropathy

9
Clinical Differentiation of Lid Retraction from
Proptosis

• Measurement using prisms or special ruler
  (exophthalmometer)
• OR with sclera
• seen above iris
• Observing position of lower lid (sclera seen
  below iris proptosis, lid intersects iris lid
  retraction)

Normal position of eyelids
Proptosis
Lid retraction
10
Lid Lag in Thyrotoxicosis
Normal Lid Lag
11
Clinical Characteristics of Localized Myxedema

• Raised surface
• Thick, leathery consistency
• Nodularity, sometimes
• Sharply demarcated margins
• Prominent hair follicles
• Usually over pretibial area
• Non-tender

12
Graves Disease - Localized Myxedema
Nodularity
Thickened skin
13
Thyroid Acropachy
Clubbing of fingers

• Clubbing of fingers
• Painless
• Periosteal bone formation and periosteal
  proliferation
• Soft tissue swelling that is pigmented and
  hyperkeratotic

Periosteal bone formation and periosteal prolifera
tion
14
Causes of ThyrotoxicosisDivided by Degree of
Radioiodine Uptake
15
Integumentary System in Thyrotoxicosis

• from Literature Gordon
• Excessive sweating 48-91 78
• Warm /or moist skin 31-83 77
• Heat intolerance 44-89 64
• Accelerated hair loss 20-40 63
• Thin skin 56
• Palmar erythema 8 34
• Cold intolerance 1-12 5
• Cool /or dry skin 1-7
  2
• Onycholysis 5-13

Prospective study - Unpublished
16
Onycholysis of Thyrotoxicosis
Distal separation of the nail plate from nail
bed (Plummers nails)
17
Cardiorespiratory System in Thyrotoxicosis

• from Literature Gordon
• Pulse gt79 beats/minute 94-100
• Palpitations 66-89 61
• Dyspnea on exertion
• (without CHF) 45
• Peripheral edema 9-35
• Atrial fibrillation 9-22
• Cardiomegaly /or
• congestive failure (CHF) 9-15 18
• Peripheral edema (without CHF) 13

Prospective study - Unpublished
18
Gastrointestinal System in Thyrotoxicosis

• from Literature Gordon
• Weight loss (gt10 lbs) 52-84 67
• Increased appetite 20-65 52
• Hyperdefecation /or
• diarrhea 19-56 36
• Decreased appetite 9-27 18
• Constipation 1-17 13
• Hepatomegaly 11
• Weight gain (gt10 lbs) 2-23 7
• Splenomegaly 2-10 1.5

Prospective study - Unpublished
19
Gynecomastia and Thyrotoxicosis

• Presenting manifestation (unusual)
• Occurs in 0-83 of patients
• Onset during thyrotoxicosis
• Disappearance after euthyroidism occurs

wide range probably indicates differences in
examining technique
20
Neuromuscular System in Thyrotoxicosis
1

• from Literature Gordon
• Tremor 66-97 88
• Nervousness 59-99 85
• Fatigue or tiredness 74-88 79
• Hyperkinesis, restless,
• /or rapid movements 26-75 63
• Weakness 69-70 60
• Headache 52
• Hyperactive reflexes 50

Prospective study - Unpublished
21
Neuromuscular System in Thyrotoxicosis
2

• from Literature Gordon
• Insomnia 49 47
• Proximal muscle
• weakness 32-43
• Myalgias or stiffness 31
• Decreased muscle mass 30
• Paresthesias 24
• Joint pain 2-27 23
• Distal muscle weakness 15
• Frank psychiatric disorder 10-20

Prospective study - Unpublished
22
The Deep Tendon Reflex in Hypothyroidism

• The more commonly appreciated reflex amplitude
  is increased in hyperthyroidism
• However, the deep tendon reflex time is also
  shortened in hyperthyroidism
• The intensity of hammer percussion should be the
  lightest possible stroke that evokes the reflex
• Time and amplitude are interfered with if there
  are problems with relaxation of the patient,
  inertia because of interfering surfaces or gravity

Hyperthyroid
TIME
Normal
23
Hyperactive Deep Tendon Reflexes in Thyrotoxicosis
24
Frequency of Neuromuscular DisordersAssociated
with Thyrotoxicosis

• Myopathic Disorder
• Myopathy due to thyrotoxicosis gt50
• usually proximal and mild to moderate
• Hypokalemic periodic paralysis lt1
• Myasthenia gravis lt1

Reported as high as 13 of Asian (Oriental) men
with thyrotoxicosis and 2 of all Asian
(Orientals) with thyrotoxicosis. Also, 90 of
patients with thyrotoxic hypokalemic periodic
paralysis occurs in Asian (Orientals). This is
most common cause of hypokalemic periodic
paralysis.
25
Thyrotoxic Periodic Paralysis

• Most common cause of hypokalemic periodic
  paralysis
• Flaccid paralysis
• Lower extremities affected most often
• Ocular and bulbar muscles uninvolved,
  respiratory muscles rarely involved
• Most often starts during sleep
• Precipitated following exercise, high salt
  intake or high carbohydrate diet
• Hypokalemia during the paralysis

26
Embryology of the Thyroid Gland

• Medial portion of thyroid gland
• Arises at the base of the tongue posteriorly, the
  foramen cecum - lack of migration results in a
  retrolingual mass
• Attached to tongue by the thyroglossal duct -
  lack of atrophy after thyroid descent results in
  midline cyst formation (thyroglossal duct cyst)
• Descent occurs about fifth week of fetal life -
  remnants may persist along track of descent
• Lateral lobes of thyroid gland
• Derived from a portion of ultimobranchial body,
  part of the fifth branchial pouch from which C
  cells are also derived (calcitonin secreting
  cells)

27
Lingual Thyroid (failure of descent)
Verification that lingual mass is thyroid by its
ability to trap I123
Lingual thyroid Chin marker
Significance May be only thyroid tissue in body
(70 of time), removal resulting in
hypothyroidism treatment
consists of TSH suppression to shrink size
28
Lingual Thyroid (failure of descent)
29
Disorders In Patients Who Received Head and/or
Neck Radiation

• Benign tumor or goiter of thyroid - most common
• Papillary and follicular carcinoma of thyroid
• Primary hyperparathyroidism
• Salivary gland tumors
• Neurogenic tumors
• Basal cell and squamous cell carcinoma of skin
• Mucosal carcinoma of oropharynx and larynx
• Glioblastoma
• Soft tissue tumors

30
Differential Diagnosis of a Painful Thyroid
Disorder Frequency Subacute granulomatous
thyroiditis Most common Hemorrhage into a
goiter, tumor or cyst with or without
demonstrable trauma Less common Acute
suppurative thyroiditis lt1 Anaplastic
(inflammatory) thyroid carcinoma lt1 Hashimotos
thyroiditis lt1 TB, atypical TB,
amyloidosis lt1 Metastatic carcinoma lt1
31
I hope you have enjoyed this course. Please do
not copy any of these slides as they contain
sensitive material and individual approval may
not have been understood, when the photographs
were taken, especially in this era of
computers. Donald L. Gordon, MD.